Axial Axis Metastasis

Axial axis metastasis remains a challenge for surgical as well as other treatment modalities, like chemotherapy, immunotherapy, and radiotherapy. It is unequivocal that surgery provides pain improvements and preservation of neurological status, but this condition remains when associated with radiotherapy and other treatment modalities. In this review, we emphasize the current forms of surgical treatment in the different regions of the spine and pelvis. The evident possibility of percutaneous treatments is related to early or late cases, and in cases in which there are greater risks and instability to conventional surgeries associated with radiotherapy and have been shown to be the appropriate option for local control of metastatic disease.

Keywords
spine; pelvis; bone neoplasms; spontaneous fracture

Authorship

Marcio Fernando Aparecido de Moura Address for correspondence Marcio Fernando Aparecido de Moura, Msc. PhD, Hospital de Clínicas da UFPR, R. Gen. Carneiro, 181 - Alto da Glória, Curitiba, PR, 80060-900, Brazil (e-mail: mm.mm1966@gmail.com).

Oncology Orthopedics and Spinal Surgery, Hospital de Clínicas e Hospital do Trabalhador, Universidade Federal do Paraná, Curitiba, PR, BrazilUniversidade Federal do ParanáBrazilCuritiba, PR, BrazilOncology Orthopedics and Spinal Surgery, Hospital de Clínicas e Hospital do Trabalhador, Universidade Federal do Paraná, Curitiba, PR, Brazil

Department of Surgery, Universidade Federal do Paraná (UFPR), Curitiba, PR, BrazilUniversidade Federal do ParanáBrazilCuritiba, PR, BrazilDepartment of Surgery, Universidade Federal do Paraná (UFPR), Curitiba, PR, Brazil

https://orcid.org/0000-0001-6169-1106

Suely Akiko Nakagawa

Oncology Orthopedics, Hospital AC Camargo Câncer Center, São Paulo, SP, BrazilHospital AC Camargo Câncer CenterBrazilSão Paulo, SP, BrazilOncology Orthopedics, Hospital AC Camargo Câncer Center, São Paulo, SP, Brazil

Diego Pereira Sanches

Oncology Orthopedics, Hospital do Trabalhador, Universidade Federal do Paraná, Curitiba, PR, BrazilUniversidade Federal do ParanáBrazilCuritiba, PR, BrazilOncology Orthopedics, Hospital do Trabalhador, Universidade Federal do Paraná, Curitiba, PR, Brazil

Karina Costa Maia Vianna

Hospital do Trabalhador, Universidade Federal do Paraná (HC-UFPR), Curitiba, PR, BrazilUniversidade Federal do ParanáBrazilCuritiba, PR, BrazilHospital do Trabalhador, Universidade Federal do Paraná (HC-UFPR), Curitiba, PR, Brazil

Address for correspondence Marcio Fernando Aparecido de Moura, Msc. PhD, Hospital de Clínicas da UFPR, R. Gen. Carneiro, 181 - Alto da Glória, Curitiba, PR, 80060-900, Brazil (e-mail: mm.mm1966@gmail.com).

Conflict of Interests

The authors have no conflict of interests to declare.

SCIMAGO INSTITUTIONS RANKINGS

Figures

Figures (5)

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Fig. 1
(A) illustrates the cross section of the spinal cord and the possibilities of metastases in the spinal cord, intraespinal, intradural, extradural intracanal, as well as extraforaminal intraradicular and bone vertebral metastasis. (B) scheme of the distribution of sensory spinal tracts and the motor tract, a and b) gracile and cuneiform fasciculi: sensitivity of fine touch, vibration and position; c) lateral corticospinal tract (pyramidal), movement ability tract; d) lateral thalamic thorn tract, pain and temperature tract; e) anterior thalamic thorn tract, pressure sensitivity tract; f) anterior corticospinal tract (pyramidal), movement ability tract; g) spinocerebellar tract (Grower spine), proprioception; h) spinocerebellar tract (Flechsig fascicle), proprioception; m) central motor area, posterior and anterior horn. Compression usually occurs from anterior to posterior, and progressive sensory loss will go from pressure area to motor area to fine sensitivity.

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Fig. 2
Weinstein, Boriani, Biagini (WBB) classification (1997). The zones begin” from the spinous to the previous process, clockwise, the prefixes A-E are the radial levels of vertebral involvement: A: paravertebral soft tissues; B: superficial intraosseous; C: deep intraosseous; D: extra-dural extra-osseous; E: intradural extra-osseous. Allows planning of vertebral resection.

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Fig. 3
Graduation of 6 medullary compression points (6 points ESCC- epidural spinal cord compresion)—0 - only bone disease; 1a - contact without deforming the thecal sac; 1b - deformation of the tecal sac without touching the medulla; 1c - deforms the tecal sac and touches the medulla; 2 - spinal compression but with visible liquor around the spinal cord; 3 - spinal cord compression without visibility of the liquor around the medulla—allows neurological understanding with morphological analysis of epidural compression.

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Fig. 4
Female patient, 47a chondroblastic osteosarcoma, 2008, presented with pathological fracture of the right distal femur and underwent neoadjuvant treatment with right knee stent. In 2017, she developed disseminated bone metastases and recurrence in the right popliteal fossa. She presented sacral lesion with severe pain when walking, and she was able to ambulate again after spinopelvic fixation. The patient died in 2020 from sepsis of the urinary tract.

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Fig. 5
Patient, 67a Yellow F. History of Papillary Thyroid Carcinoma, submitted to several percutaneous procedures, radiofrequency associated with “vertebroplasty”, and cementation of lesions around the sacroiliac joint of the acetabulum (acetabuloplasty) and percutaneous fixation of the proximal femur, keeping it in functional stability without interrupting systemic treatment.

Fig. 1 (A) illustrates the cross section of the spinal cord and the possibilities of metastases in the spinal cord, intraespinal, intradural, extradural intracanal, as well as extraforaminal intraradicular and bone vertebral metastasis. (B) scheme of the distribution of sensory spinal tracts and the motor tract, a and b) gracile and cuneiform fasciculi: sensitivity of fine touch, vibration and position; c) lateral corticospinal tract (pyramidal), movement ability tract; d) lateral thalamic thorn tract, pain and temperature tract; e) anterior thalamic thorn tract, pressure sensitivity tract; f) anterior corticospinal tract (pyramidal), movement ability tract; g) spinocerebellar tract (Grower spine), proprioception; h) spinocerebellar tract (Flechsig fascicle), proprioception; m) central motor area, posterior and anterior horn. Compression usually occurs from anterior to posterior, and progressive sensory loss will go from pressure area to motor area to fine sensitivity.

Fig. 2 Weinstein, Boriani, Biagini (WBB) classification (1997). The zones begin” from the spinous to the previous process, clockwise, the prefixes A-E are the radial levels of vertebral involvement: A: paravertebral soft tissues; B: superficial intraosseous; C: deep intraosseous; D: extra-dural extra-osseous; E: intradural extra-osseous. Allows planning of vertebral resection.

Fig. 3 Graduation of 6 medullary compression points (6 points ESCC- epidural spinal cord compresion)—0 - only bone disease; 1a - contact without deforming the thecal sac; 1b - deformation of the tecal sac without touching the medulla; 1c - deforms the tecal sac and touches the medulla; 2 - spinal compression but with visible liquor around the spinal cord; 3 - spinal cord compression without visibility of the liquor around the medulla—allows neurological understanding with morphological analysis of epidural compression.

Fig. 4 Female patient, 47a chondroblastic osteosarcoma, 2008, presented with pathological fracture of the right distal femur and underwent neoadjuvant treatment with right knee stent. In 2017, she developed disseminated bone metastases and recurrence in the right popliteal fossa. She presented sacral lesion with severe pain when walking, and she was able to ambulate again after spinopelvic fixation. The patient died in 2020 from sepsis of the urinary tract.

Fig. 5 Patient, 67a Yellow F. History of Papillary Thyroid Carcinoma, submitted to several percutaneous procedures, radiofrequency associated with “vertebroplasty”, and cementation of lesions around the sacroiliac joint of the acetabulum (acetabuloplasty) and percutaneous fixation of the proximal femur, keeping it in functional stability without interrupting systemic treatment.

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[1] Address for correspondence Marcio Fernando Aparecido de Moura, Msc. PhD, Hospital de Clínicas da UFPR, R. Gen. Carneiro, 181 - Alto da Glória, Curitiba, PR, 80060-900, Brazil (e-mail: mm.mm1966@gmail.com).